Hurtling toward the next phase

I have searched but I cannot find the flying trapeze story I read a few years ago that explains my life, so I’ll paraphrase and add to it here:

I swing back and forth preparing for my next take off. I have prepared, but I know that this leap is longer and more challenging than ever before. In spite of a long line of successful jumps, there have been some near-misses, some full on misses, some blood, scrapes and even some still healing deeper wounds. This time I jump, my husband is watching and waiting readying himself for his jump into dissertation land and as we prepare Zo waits by ready to take off with us.

Well MiM friends, it’s official, I have accepted a position as a Pediatrician in my dream clinic. I’ll be back in DC working at an academic center-affiliated community clinic. I did my community pediatrics rotation there as a medical student and so many of my respected supervisors and medical school friends are still there.

Interviews were a whirlwind. I met so many nice people, got lost countless times, learned even more about what I need, want, and will compromise on.  

And now onto school finding. Every day I have a mini-freak out when I think about Little Zo starting pre-k. Our cherubic toddler has been replaced by an almost 4 year old hilariously funny and extremely sweet rib-protruding knock-kneed ball of energy. And then I freak out more about making pick up and drop off work and I pray so intensely that we find the right environment for him and that we will find balance so I can rock my boards and O can finish his dissertation expeditiously. I wish I could transplant his daycare to DC.

And house hunting on a single income in a very tight housing market is not my favorite thing to do but I guess house hunting without the beloved Property Brothers will always be lackluster. We have several leads on promising houses and are heading up next weekend prepared to make an offer. Can’t wait to have our first home secured and then on to do-it-yourself projects for years to come.

This jump seems epic. Push-pull-push-pull, forward backward forward backward, take off.

MiM Mail: Having children with both parents in training

Hi Mothers in Medicine,

I am a longtime reader of the MIM blog, and really appreciate being able to read your stories. You are inspiring! I am writing to request advice, especially from those who had children during medical training with a medical spouse (or spouse with a very demanding career).

I am nearing the end of my 1st year of med school, and my husband is a resident in a surgical subspecialty, with 4 more years to go. We would love to have a large family (4-5 kids), and are a bit older than the average med student/resident so waiting to have kids until after training isn’t realistic. We are ready to start our family, but I am a little nervous about being the primary caregiver (with outside help) as a medical student. I know that my husband will make a wonderful father, but given his 80 hr weeks at the hospital he won’t be able to contribute as much time-wise. Having kids is super important to us, and some days I question whether medicine was the right choice for me, but I am doing well academically and I think I am on the right path.

Our tentative plan (acknowledging things don’t always go as planned!) is as follows, and I would love to hear your thoughts about pros/cons, other ideas and tips on how to make it work! We are considering aiming for baby #1 at the end of 3rd year. I would like to take a semester of maternity leave, then complete my year of elective rotations (daycare or a visiting Grandma for childcare), have baby #2 and take another semester off for maternity leave before starting residency. Has anyone tried to/ succeeding in taking 2 separate semesters off rather than a year at once for maternity leave? Is completing 80% of my clinical rotations while pregnant realistic? Any advice about the timing of clinical rotations? I hesitate to talk to my school’s administration, when did you approach them? Is starting residency with a 2 yr and 6 mo doable? Is it really possible to do a “part-time” residency? How difficult is it to take the full 12 wks of FMLA for maternity leave during residency? Am I crazy for thinking that this sounds like a reasonable plan? Have you been through something similar and barely survived, or were you able to thrive? Any advice would be greatly appreciated!

-K

Guest post: Oral boards anxiety

Tonight I ran a Google search "thoughts about the oral OB-GYN boards" and your site came up. I read all your comments in the hope I will find some relief of my anxiety. I did not.

You see, I passed my oral OB-GYN boards 6 years ago. I can't remember being this petrified prior to taking them and I felt ok after the examination has ended. Now, it's time for round two: my oral subspecialty Boards. I can't figure out why, but this time around I am mortified. Everything about it, the clinical part - am I thinking like a subspecialist? am I dissecting this disorder process in 10 different way for analysis? The research part (the scariest of all) - am I going to survive the probing questions regarding the study design and power, the statistical significance of my results, is my data "worthy" and my results "meaningful" to their scientific expectations? An then, the genetics - will I remember what findings fit the puzzle of what disorder, how well am I counseling my patients? I wish I could find my answers before I walk into that room to go through it all for yet again, the second longest three hours of my life.

I hope I will survive them next week and not have to repeat this ever. Although I am as prepared for it as much as I will ever be, I still feel "On a wing and a prayer."

Speaking about a prayer, I think I could use one in just a few short days.



A little bio about me:
IronGirl practices Maternal-Fetal Medicine in Midtown America, mother of two beautiful children Jek 13, and Lui 10, wife to Mr. Bold, non-MD guy that likes to play with fire and ice for a living, awesome hubby, caring partner, and multitasked oriented sports-dad.

IronGirl likes to spend her free time (is there any time that's free, hmm...) running, biking, swimming, racing, and sometimes just chilling by a bonfire listening to Flamenco music. And now, getting initiated into blogging.

Guest post: ADHD or ASD?

My oldest child is eight years old. He is funny, super-smart, and charming. He once made up a song about how much he loves me.

He has also recently been diagnosed with ADHD.

You see, ever since he was very young, I knew there was something different about him. I was just finishing my second year of medical school, and he was my first child. But I knew. In infancy, he stared at objects of interest with an intensity of focus that was mesmerizing. When he began to speak, he spoke eloquently (seriously!) and argued his points with logic well before the age of 2. He never joined in group activities, but observed them solemnly and seriously. He slept poorly. He had explosive, long-lasting, inconsolable tantrums about everything from transitions to meals to seams in his socks. He had severe separation anxiety at school drop-off, which lasts to this day. He had (has) exquisite sensory sensitivities. He remains a slave to routine and ritual (and reacts poorly indeed when things change). He can talk for hours about black holes and superheroes. He clearly loves his siblings and his parents, but all interactions must be on his terms.

I thought – I still think – that he has an ASD. Asperger's. It's him to a T.

I could write for pages and pages about my son and his symptoms and his birth and neonatal course and December birthday and GI problems and build my case to you – fellow physicians and mothers – as to why I am so sure that ADHD is the wrong diagnosis. But at the end of the day, in my mind, the letters don't really matter. All I want is someone out there to help us better parent our child. The way he relates with the world is not "neurotypical", that is for certain. But how can I help him, who he is, grow and thrive and make his way in peace and confidence in this world? My husband and I have done a lot which I think has been very good for our son. But we were at an impasse. We took him to the pediatrician because we were looking for help. Guidance.

So now we have this diagnosis. Maybe it is accurate, maybe not. I am truly not writing this as an argument one way or another for his actual diagnosis. The essence of my post relates to my own reaction to hearing the diagnosis. I just thought: no. Not that. NO. I would have accepted "ASD" – I suspected it. I may have accepted some kind of anxiety disorder. Or – no diagnosis! That's just who he is, and here's how we can help you. That would have worked. But ADHD… I absolutely balked. Why?

I feel that in popular media, ASD is portrayed as a diagnosis which is blameless. Autism support groups, parent groups, blogs, articles, and fundraising abound. There are supports for parents, and children can receive evidence-based treatment (at least in my province). We have specific screening tools in Ontario, for use at the 18 month well child visit, specifically to screen for ASD. And don't get me wrong – rightfully so. Early intervention works and should be promoted. Also, I'm NOT saying parents of children with ASD have it easy. Not at all.

Now I contrast with ADHD. I feel that ADHD is portrayed more as blame-able (i.e. on the parents) and less "real." ADHD is often the butt of jokes or widely derided as an "excuse" for poor behaviour. I do not know of any screening for ADHD that is done in routine well-child visits. I do not see articles or blogs about parenting a child with ADHD. I don't hear about ADHD research fundraising activities. I'm not saying they don't exist. But I do not think that they are as "out there" in popular media.

I am not a pediatrician, nor a psychiatrist, but I understand that both ASD and ADHD are considered neurodevelopmental disorders which arise through an interplay between genetics and "environment" (that lovely catchall for everything from prenatal exposure to substance X to pollutants to diet and so on). I do not think the medical community considers one or the other of these diagnoses to be the parents "fault." But I do think, that deep down (and I am ashamed to say this), I am afraid of my son being diagnosed with ADHD. Afraid of the looks. The blame. The rolled eyes. The label. Afraid of the consequences of starting him on medication – or not doing so. Afraid of possible misdiagnosis and its consequences. Afraid of grandparents finding out and having to deal with the inevitable questioning and doubt. Afraid that I will feel less sympathetic, more frustrated, less supported, more alone. Simply afraid.

I know that my child is who he is, despite any diagnosis or lack thereof. I know that one diagnosis is not "better" than any other. Diagnosis won't change who he is. I want to be clear that I am not saying I want or favour a certain diagnosis for my child. Nor am I implying any judgement of any of your children with these diagnoses, or you! Rather, I write to explore my own reaction to this situation, and to consider the reasons behind it, even though in doing so, I seem to have uncovered my own fears and biases.

What do you think of when you meet a child with ADHD? The child might be a patient, a niece or nephew, a classmate or friend of your child. How does that differ from your feelings when you meet a child with ASD? Are you more or less sympathetic? Understanding? Willing to forgive / accept / work with the child's behaviours?

I want to parent my child as best as I can. I want what we all want – I want him to feel loved, confident, and secure. I want him to thrive. I know that the letters won't change who he is. Despite my fears, I also know that the letters won't change who I see, as his mother: a very unique and special child with some incredible talents and some special challenges to work with. The question is: will the letters change what others see?

Meditation

In the past, I've made several attempts to meditate regularly. But I've always failed for the following reasons:

-- meditation is boring

-- meditation is hard

-- I don't have enough free time... Or at least, I'd rather spend my free time doing something that isn't boring or hard

But I've decided to challenge myself. I keep reading about all these health benefits of meditation, so I'm gonna give it a fair try. I got the app for my phone, and I'm going to do it for 15 minutes at least four days a week for a month.  I'm posting my goal here with the Internet as my witness so that I will stick to it.

At the end of the month, I expect all my problems to be solved.

A Teaching Moment

Genmedmom here. This was going to be a sweet little post about a teaching experience from my clinic yesterday. A patient presented with a classic clinical finding, and I knew that one of the other providers had a few students with them. So I asked the patient if I could bring in a student or two, and she cheerfully assented. It's been a very long time since I was involved in clinical instruction, and I enjoyed it.

I searched the web for a photo image or clip art to accompany this piece, something that illustrated a female doctor teaching medicine to students. I typed in all sorts of search phrases, but the vast majority of clipart or stock photos clearly depicting a doctor instructing medical students showed male doctors- and often with a lovely nurse standing by.

The best approximation of a female teaching physician that I could find was this (*and, this image is totally copyright of Disney Junior):

I mean, it's a good thing that Doc McStuffins exists, and that this image and the DVD it advertises exist. Not to imply a commercial plug; I must emphasize, I have no financial disclosures here! I just love the example she sets for little girls, all the pink and purple notwithstanding. She's a doctor, and her mom is too. They're African-american. The show is a hit. It's awesome.

So, why was this the only image I can find of a female doctor actively teaching medicine to students? This was mind-boggling to me. I needed to understand. I needed data to interpret; it's just my research fellowship training.

And I found data. According to the Kaiser Foundation, there are 893,851 practicing physicians in the United States, and 32% of those are women. The American Association of Medical Colleges (AAMC) has published a detailed breakdown of U.S. medical faculty, by rank, sex, race/ethnicity and specialty. Per their data for 2014 (which can be found at The AAMC website Reports page):


Of the 155,089 total U.S. medical faculty, 62% are male and 31% are female.

Of those that are at the higher ranks, as in professor or associate professor, 72% are male and 28% are female.

The breakdown by race/ ethnicity is frankly depressing, and I didn't even want to figure it out. For those of you that enjoy crunching numbers, have at it- there's tons of other good data in there as well.

It's clear that we need more women physician role models and teachers of medicine. So, what are the obstacles?

Well, in my case.... When I started by current position at a major academic medical center, I was involved in a medical school course geared towards fostering empathy and communication skills. I think every med school has these now, Patient/Doctor/Society type courses. But then I became pregnant with Babyboy, and realized I would be out on maternity leave for a chunk of the next session, so I never signed back up. Now, with two very young kids and enough to balance as it is, I'm not sure I want to take on the added responsibility of teaching...Not just right now.

I know my kids will get older, and I hope to get involved with teaching again someday. Likewise with medical volunteer work. I'm half Latina, I speak Spanish, and I've lived and worked in Latin America. At some point, I'd like to get re-involved in that work, as well as be a mentor for Latina students...Someday.

Meantime, I very much enjoyed interacting with our students over a case of erythema multiforme this week.

I'm curious what the doctor-moms out there think of these numbers. Do we need more female physicians teaching medicine? How about female minority physicians teaching medicine? And what do others think about Doc McStuffins?

MiM Mail: How are your kids that grew up with a Mother in Medicine?

Hi MiM,

I am an M1 with a 7 month old baby. I was so excited to start but phew, it has kicked my butt. I have great childcare and a very supportive partner but I struggle with constantly feeling behind - behind on house work, on study, time with friends. And of course, my sweet daughter. I worry a lot - is she going to be ok? Will she still be strongly attached? Will I miss being home with her more when these "little years" have passed? I would love to hear your thoughts on these. Not so much "mom guilt" but for those whose children have grown up while they have had a career in medicine - how is your relationship with them ? How are they? Do you regret being gone? Any tips as to how to treasure the time you do have without being bogged down in the never-ending "to-do" list? I spend my days off with her trying to do laundry and purée baby food while longing to just play. Balance is hard and I'm feeling the tension.

A

MiM Mail: Pressing advice needed for an IMG

Hi MiM,

I need some advice.

I’m a 34yo IMG who graduated and returned back to the USA a few years ago, keeping busy with research and odd biomedical-related jobs, but I’d basically given up hope that residency (and medicine) was in my future years ago. During that post-graduate time I also met and married the love of my life. We’ve been trying to start a family for the last couple of years, but were eventually diagnosed with unexplained infertility. It’s been incredibly frustrating – we’re both perfectly physically/genetically healthy and under 35, but what happens so naturally for others just wasn’t happening for us.

Over three months ago, in December, an opportunity fell in my lap to interview for a one-year preliminary position in Internal Medicine with a large community program that is currently not in the Match. The interview went well, I was immediately offered a position, and signed a letter of intent on the spot. During that time, knowing that we were not getting any younger and you just never know what the future holds, we decided to progress on to IVF. First attempt was a bust, and absolutely emotionally crushing for both of us. Then last month we transferred a couple of frozen embryos into me, and yesterday I got the results from my first beta-hCG blood test – big ol’ positive! In fact, it’s looking like it might well be twins (instant family!). I’m still being incredibly cautious about my optimism, but we’re both certainly happy at the news.

So now I’m left wondering how to handle this upcoming prelim position; they sent me my contract a couple of weeks ago, but I admit I’d been dragging my feet and sitting on it for a while, wondering how this whole IVF thing would play out and how I could/would juggle the two. In an ideal world, I could talk to my program director (who is incredibly nice, so far) about the possibility of starting this one-year gig next year (they’ll still need interns next year, right?). I know this is a job, not some schooling I can defer, but it seems, based on anecdotes here on MiM and elsewhere, that it’s a remote possibility. That being said, I know I’m incredibly replaceable, and I already got the sense that I was offered this position out of pity. My husband and family and friends say to sign the contract (otherwise I lose leverage) and then discuss the pregnancy with the PD and hope for the best. Meanwhile I’m worried that once I sign the contract, I enter into a binding agreement for the year, which makes it difficult to potentially postpone it until next year (if that’s an option). I wish I could discuss it with my PD, but I’m afraid of scaring him away to the point he’ll just decide I’m too much trouble and just walk away.

Maybe I’m just over-reacting, but I’m really not looking forward to the idea of basically spending the last two-thirds of my first pregnancy as an IM intern at a busy community hospital. I know from stories that internship and pregnancy by themselves can be physically and mentally difficult (and frankly, part of me fears them both), so to have to deal with them concurrently – especially as a ‘geriatric’ pregnancy, possibly with multiples – is just NOT something I’m looking forward to dealing with. It’s particularly worrying for me because I know this is an opportunity for me to shine and potentially continue on within the field of medicine, but I have the very real concern that I will simply not be at my best if I’m pregnant during internship and therefore not do my future any service.

I know I put myself in this position, but I'd welcome any advice!

Thanks,
DrDel

MiM Mail: Ever too late for medicine?

Hello, I am a 34 year old working mother of two young children (3.5 years old and 14 months). I have been working as a research scientist in the pharmaceutical industry for a number of years now. I have been thinking of becoming a doctor since 2005. I applied to one local university in 2012, received an interview but was put on the waiting list thereafter. My husband is very supportive of my decision to pursue medicine and I would like to reapply at some point in the future. There are a few things holding me back from applying any time soon though. We would like to try for a third baby before it becomes "too late" age-wise. Also, I'm realizing more and more that I like to be heavily involved in my children's lives. I enjoy the home-making side of my life very much and I find it difficult being apart from them for extensive periods of time (my current job is about 40 hours a week and I'm ok with that because I get to have dinner with the family, put kids to bed and have weekends with them). I very much want to pursue medicine but I'm so scared of losing the family side of my life and that I won't really be a part of my children's memories if I'm busy in medical school and then long hours in residency and as an attending. I have no problem studying (I love it!) and working hard, but I want to be there for my family. So my question is, would it be completely unreasonable to postpone medicine for a few years, maybe 5? 10? Or whatever it takes for me to feel that I have nurtured my children to the point where they are ok with me not being there often? (I have heard of women successfully entering medicine in their 40s and even 50s). I have no idea when I would feel "ready," and I know that age can be a factor when you want to pursue certain specialties, but I'm actually interested in family medicine with a focus on OB. I'm just having a hard time envisioning myself being both a good mummy and a good doctor at the same time. I feel like one area will suffer, and for me, my family is my top priority. I have several doctors in my extended family and have talked extensively with them but they are all males so I have not had much female perspective other than what I have been researching online and reading in books. I would really appreciate your feedback on my dilemma. Thank you so much for your time.

MiM Mail: (Un)happy match day - "It doesn't matter what YOU want"

As match approaches, it is with a heavy heart that I await the results.

This is a story which has been culminating over the years, and in fact, I have many unsent emails addressed to MiM which tell the tale. I am a 4th year medical student with two girls - a preschooler and a toddler. Both of these I gave birth to during medical school (I "took a year off" and did an MPH between 3rd and 4th year). I am married, and it is not a match made in heaven. Few relationships are perfect, but I feel like ours has some really deep underlying issues that perhaps make it stand out. We had a fun relationship in the beginning - but we got married more so because of an unplanned pregnancy. We were legally married in a courthouse. It was important to him to get married prior to the birth because he was already plotting his custody rights. I didn't tell my mother, who would have counselled me against it (and she would have been right), and none of my family or friends were in attendance. I worried about our significant age difference, but he promised me support, and we framed the relationship in that way - he has no competing career, which frees me up to pursue mine while having a secure family life. (Perhaps something like this.)

I wanted to send this story in because the title of the previous mailbag letter, "Whose dreams come first?" struck me. The reason that this resonated with me so much is that my husband told me when I was explaining my rank list, "It doesn't matter what you want."

Having children during medical school has been extremely draining, and now that I am plotting my career path, I wish I had more control over what I wanted to be and where I wanted to go. I am an excellent student and work extremely hard. Despite being a full time student, I have also taken extensive care of my children, especially as babies. I have "studied from home" while taking care of my children as infants for about 3/5 years of medical school/MPH (M1, M2, MPH) so that my husband would continue to have opportunities to work. Opportunities that I don't feel he ever took advantage of.

My husband and I have no family nearby and no family equivalents. As a result, all childcare responsibilities fall completely on us, unless we pay a babysitter. We did have a regular sitter 3 days a week for about one year, which I think was an overall great experience (with the exception that I felt from my perspective that we were hiring her so that my husband could work, with the implicit understanding that as a medical student I needed to work all the time, but from his perspective I was hiring her so that I could go to school while preserving his autonomy), but she went out of town and since the financial equation didn't add up (his overall work income = cost of sitter, and that includes time that I took care of the kids for him to work as well) by mutual agreement we didn't find someone to replace her.

There is not much of a culture of stay at home husbands of doctors. I have seen several blogs out there of the proud and self-sacrificing "doctor's wives" but nothing similar to that for the "doctor's husband." These blogs tell of the hard work of the male doctors, the pride of the doctor's wife in her husband's service to humanity, her story of self-sacrifice for her husbands career, helpful recipes, and parenting tips. My husband doesn't feel this way about my career at all. Perhaps it's because this culture doesn't exist for him. We are essentially at odds about my schedule, my need to study, the housework, the possibility of needing to move.

Because my husband decided on his own volition to be a stay at home dad, he now makes even more minimal income than before. He receives a $1000 annuity monthly from an accident.  I transfer money to him to pay the mortgage on his house/workshop and other bills. Most of it is money from my mother, and she is sending it via me to him with the understanding that he is supporting me in my career and taking care of her grandchildren. He says that he has "sacrificed" his work for my career, but in fact he adamantly did not want to get childcare and work. He has not given up financial security either - when we met, his bank account was completely overdrawn. He has recently characterized himself as been a "servant" of my "wealthy family." However, suggestions I have made that would make him more financially independent: renting his workshop space for income, getting a regular job, etc, have previously been shot down as inconceivable. We paid his leftover defaulted college loans - from almost 30 years ago! - with our tax return credits. I have also enabled him to pay off credit card debt. Meanwhile I feel like I have sacrificed much of the quality of my medical training for him, having lost out on the experience of a normal M1 and M2 year and career development opportunities along the way, but still taking on full expenses for the family either via loans or via my mother's contributions.

Rewind to the end of 3rd year: I am 9 months pregnant and concurrently preparing for the medicine clerkship exam,  starting MPH coursework, and studying for Step 2CK. I destroy the exams because I work hard. I am a machine! Woot! But things really go downhill over the next year. While in labor, I try to write a paper. It exemplifies my experience over the next year: working in pain. The intense emotional pain of trying to do well in school while your infant cries. I had done something similar in M1 year, but the memorization was much more tolerable than the reading and paper writing. And things are much more complicated now with two kids. My husband had encouraged me to do the MPH because of financial reasons - the fact that I will continue to have loans available and that my mom will continue to contribute to us if I am in school. After trying to write my paper between contractions, I give birth the following morning. It is a joyous day. Shortly after, I initiate total 24/7 care of our second child while taking 6 online courses, about 60 hours per week of work. His contribution is taking care of our oldest about 2/3 to 3/4 of the time, and taking her to school every morning. I work from 9pm-3am every night (the hours she most predictably sleeps) plus whatever else I can get my hands on. Even with this, he is pressuring me to do more school pickups for our oldest so that we are being "fair." In all this time, he theoretically could be working at least between 9am and 3pm M-F (and longer when I do pickups) but apparently does not since my mom is still paying the bills. I am feeling like sh*t, alone at home (online courses), taking care of baby, working, doing all laundry, washing diapers, most of the housework, plus the winter is complete hell and I can't even go outside for fresh air or a run because it is too cold for the baby. His first conclusion is that I am cheating on him with a classmate because I am withdrawn from him. !!!!?????! WTF ??????!!! I blow up. I tell him that I don't like him. That I could have done better. Someone younger, better looking, and more financially secure. Yes that is a very hurtful thing of me to say, which is why I guess I didn't say it until it really came to a head. And yes, I knew this about him going in, but I valued the support and partnership he promised more than any of those "shallow" things. I guess, when I felt the support slip away, I wished I had at least some of those shallow things left to hang onto.

He goes and talks to his friend who graduated from law school. Then he tells me that if I leave him, that he will keep the kids in the state. The other stuff he talked about "is between him and his lawyer."

I wish I had initiated something then (legal counsel?) but despite these misgivings, I had no plans to divorce him.  I felt like I had made the commitment, and I was going to do the best I could with it. Perhaps it was me (too picky? don't deserve better?), perhaps I would just never be satisfied with anyone, so I should try and make it work.  Living with him seemed and still seems like the only way I will ever see my children as a medical student or a resident, and they are young. They also love him and I don't want to take them away from him. I value what he provides for them as a father. So I kept it going. M4 starts and he now has finally taken over full childcare responsibilities.

He was not supportive during the application process and was more interested in my lack of sex drive than my career prospects. Then he blames me for not having worked hard enough to find a good program in our area and says I don't deserve "the best" that I should settle for "good enough." I feel like this is a recurring theme in a lot of his beliefs. He has a disdain for wealth. He calls me a "princess" for wanting to live in a nicer house and city. I am not a pro-wealth person and have a fairly nuanced view on the relationship between income and happiness, but he is full out against it, perhaps a defense mechanism for his personal lack of financial success or stability. I don't know if this attitude can be resolved. When I say that my career will bring the family financial stability, he says our kids can go to community college, take out loans, and that they would be happy living out of a van or homeless shelter. Maybe there is some element of truth to this. I think they will be happy anywhere they are with a loving family but I wonder if we can provide that.

I interviewed at 11 programs, 5 within our city and 6 around the country. In this process I have sought out advice from many people, only one of whom said I should make the "self-sacrificing" choice, most who said I should pursue my "dreams." Many have said that my husband can't keep the kids if I move out of state (they are wrong - our state favors keeping kids in the state and I confirmed this independently).

My mother called my husband and asked him if he will support me. He said he was not moving. Why? He was protecting himself from divorce because if he stays put, the state custody laws favor him, but if we move to another state and I divorce him there, then I would be more likely to maintain custody if he then moves out of state. I asked him whether in this scenario (refuse to move, keep the kids) he would continue to ask me to pay his bills? No, apparently he will get it together. Call me doubtful, but he could not pay his bills prior to having children. And wow, if he could actually work to pay the bills, then why wasn't he doing this all along? The wildly emotional thoughts running through my mind include:this man is going to take my kids from me AND live off my future income unless I do what he wants.

Long story short I submitted my rank list while sobbing. My top programs are somewhere in the middle of my list, probably never to be realized. I have given up on the possibility of living near my family - consisting of my mom and sister. In fact, I did not even rank my preferred specialty first given I was so disillusioned, and I really regret this as well. I often wish I had submitted the list I wanted and dealt with the fray rather than be here in this limbo, unable to change or withdraw my rank list. But it was my children that he threatened to keep from me. My children. It made me crazy. (He would say: no, he did not threaten that - all he said was that "I'll keep them in the state" - he is a stickler for legal language.) My mother withdrew her financial support of him and he is now calling her evil and manipulative. She will no longer help us buy a house that he would live in. Nor should she. He now says that since I'm not paying his bills that I need to share half the parenting, including school drop offs at 8:30am (long after I am supposed to have reported to the hospital), BUT that I should NOT quit medical school. I don't know if he actually expects me to do this, or if he is just holding it over my head that I CAN'T do it.

He is looking at my future resident's salary, most likely the local program I ranked first, and salivating with the income "boon" - not concerned about what it means to me. I have watched my fellow "MiM" classmates give up their dream residency for their husband's careers, and I felt bad for them. I feel less bad for those who make the practical decision because of close-by family who are supportive. Now I feel bad for myself. I do not want to pay this man's mortgage with my blood, sweat, and tears. But he has my kids, and I will not have the hours in the day to take care of them for a long, long time.

We are in counselling now and I feel worse and worse about him the more I think and talk about it. I don't think I can forgive him for the position he postured. As far as the possibility of divorce goes, I am sincerely worried that I would lose custody of my children because of my work hours. I could drop out of residency after my contractual period and then divorce him, at possible loss to my career. Then there is always the possibility of a match day miracle, whereby I get the program I actually wanted. I suppose if that happens, I will have to be nice to him if I have any hope of making the move with my family. Or, I will submit a waiver to my dream program. Or I will visit my kids on my day off. Or at this point, do I actually want that program anymore, given that I have already started to plot a career that would be better for a single mother or co-parenting situation?

I know I am not his ideal wife. I don't idolize him and will probably never be in love with him. But I have given him so much of my life. I am willing to work with him in a partnership and possibly even an affectionate relationship for mutual benefit. Perhaps I am willing to settle for "good enough" in this "romantic relationship" part of my life, but not at the expense of settling for "good enough" in the professional part of my life? He probably feels the same way. He is willing to settle for "good enough" in our relationship if we don't move and everything stays status quo, but requires my adoration to move. But I can't fake adoration. I alternate from feeling like maybe I am a "privileged princess" to think that I could actually rank the program I wanted first - big whoop, who cares, you're going to be a doctor no matter which program you go to - to feeling enraged that I worked so hard against so many odds and am placed in this situation where I have to settle.

Maybe the best solution would be to get divorced after Match but prior to graduation, drop out after the contractual 45 day period of residency or apply for a waiver, enjoy a year with my children in the interim while HE works, and apply in a more single-parent friendly specialty with the new understanding that I am restricted locally, and with a feasible plan to co-parent. Compromise like hell, but more on my terms and with more warning.

It took me some time to get oriented on my career path with some bumps along the way as a young adult. Now I feel like I am pining for my own lost potential of self-determination that I was finally on the brink of realizing. My sister recently married a nice young man she has been long distance dating for years, who will follow her unpredictable and highly specialized career anywhere, and is excited to do so, a comparison that is painfully made. I will never get to marry a nice young man who is willing to unconditionally support my career. I will never have the experience of my family celebrating my wedding day. I will never feel deeply head over heels in love with my husband. I will never have autonomy over my career. I have what I have. Such beautiful and wonderful children! So much! Everything!

But so hard.

Well, that is my long story. I don't know what kind of advice I am looking for. Past experiences? Commiseration? Strategy? A reality check?

Honoring the Pi

It's the ultimate geeky pseudo-holiday: Pi Day. A once in a century Pi Day, apparently.  When I came back home this morning after taking the boys to Tae Kwon Do, my daughter and my husband were at the computer doing some Pi education. "It's Pi Day," she notified me, "3.14.15."

It just so happened that I had been planning a huge pie bake day today--completely unaware of how fitting that was at the time.  Prior to Thanksgiving 2014, I had made only one pie in my life, maybe 10 years ago. It had turned out so poorly and so un-pie-like (mainly the crust; the crust was a disaster, harkening my former disgraceful days in organic chemistry lab) that I proceeded to avoid making pies at all costs.

Fast forward to today, I have made at least 10 pies since Thanksgiving. I am hooked. My brother and sister-in-law even gave me a pie recipe book (it rocks) for Christmas, and I'm making my way through the recipes. I even enjoy making the crust.

All butter crust- no turning back

Today, we are headed to friends' house for dinner, and I made my first banana cream pie.

Making pastry cream is no joke labor/time-wise though

Coconut cream is up next. And can't wait for fresh berries in the summer, apples in the fall.

As we get older, it sometimes feels like we did all the learning and mastery when we were younger. Residency and intense training are long over for me.  So, it feels good to master something new. Empowerment.

Plus, there's something so satisfying about making food for those I love.  But pie. That's even a little sweeter.

Happy Pi Day! May your day be filled with pie. Or math. Or just love.

Up Against The Boards

Genmedmom here.

It's been ten years since I graduated from residency. I was Med/Peds and not quite sure what I was going to do with my life. So, I took both the Pediatrics and Internal Medicine board exams, within two months of each other. I know I studied, but I don't remember feeling overwhelmed by the material or flummoxed by the practice questions. I was a resident and then a research fellow, so I'm sure I didn't have oodles of free time. Both exams were sit-down, pencil-and-paper, highly regulated, proctored, and extremely lengthy affairs. But, somehow, I passed both tests, with minimal pain. (I'm not saying I passed with the highest scores, but hey, all you need to do is pass.)

Fast forward. I've been a Medicine attending for six years, and I'm due to re-take the medicine boards. I've registered and paid and I've got a date: April 15th.

But this time around, I am struggling. Yes, I have two little kids, and may be sleeping even less than I was as a resident. Yes, I'm purely outpatient and far, far removed from acute, inpatient care. There are scads of specialists in my large, teaching hospital- based clinic, and we frequently refer patients for alot of management issues.

But I'm only studying for the Internal Medicine boards, and I've been in practice for six years. You'd think I'd be more comfortable with this material.

Now, I like to study. I'm a dork that way. In my practice, I look stuff up all the time. I earned three hundred CME credits in the course of a year just by looking things up on our favorite medical search engine (yes, you can earn CME credits that way, if you register and then print out the report). So I figured, boards, no problem.

I got the study books and the audio material in November. I read when I can (after the kids have gone to bed, or late on a weekday workday) and listen to the most BORING medicine lectures during my commute.

But, I'm just struggling. I've reviewed a fraction of the total material. I'm getting killed on the practice questions. There are huge gaps in my knowledge, that is clear.

So I'm trying to get my head around this. The re-cert is about 8 hours of testing, now done electronically in testing centers around the country. Looks like a few hundred questions, from these basic areas:

Cardiovascular Medicine
Dermatology
Endocrinology & Metabolism
Gastroenterology & Hepatology
General Internal Medicine
Hematology & Oncology
Infectious Disease
Nephrology
Neurology
Pulmonary & Critical Care Medicine
Rheumatology

There is alot of potential question material under each discipline. At this point, I won't be able to review it all, to ABSORB all the material. I don't have time.

So I'm cramming questions. I'm doing 25-question blocks, and studying the answers, trying to learn patterns, what are they likely to ask about.

The overall pass rate for the October 2014 Internal Medicine board exam was reported as 72%... Ugh. The pass rates have been steadily declining over the past decade. Why? This is, apparently, a matter of much lively debate. In one fun article from the NEJM website, several hypotheses are presented. One conspiracy-theory hypothesis purports that the people that write the exam and charge us to take it have made it harder so that they can charge us to take it more times. Like, it's a money-maker. Other hypotheses include that we're losing the ability to study effectively, because we CAN look everything up on medical search engines... Oh.

So, I hired a sitter to get me 100% protected time on Saturday afternoons; I registered for a boards review course next week; I slashed my clinic hours to two hours per session for the three weeks leading up to the exam; and I limited my time writing blog posts to about thirty minutes a week total (ha!) so I can CRAM.

How does everyone else study for their boards?

Career poll: if you weren't a doctor, what would you be?

Since beginning my clinical rotations as a medical student, I have been exposed to so many interesting, dynamic jobs within health care that I never knew existed such as Recreational Therapy, Occupational/Physical Therapy, Respiratory Therapy, Doula, Midwife, Lactation Consultant, Clinical Social Worker, the list goes on and on.

As someone who regularly follows MiM guest posts and who talks to many premedical students, I always find it interesting that exposure to other fields in medicine is so lacking. There are so many different ways to become a health care provider and though Doctors are among the highest in the hierarchy, without a diverse group of providers we not only fail to provide the best service to our patients, but we often fail to address core issues that determine health outcomes. 

With that said, for the physicians around:

• if you weren’t a doctor what medical professional would you be or would you choose a completely different field?

And for those in training:

• what other careers in medicine have you researched, considered, or shadowed in? What did you think?

My answers:

• If I hadn’t become a doctor, I would be a Recreational Therapist with a focus on alternative methods such as massage and reiki or a Doula/Health Coach/Life Coach/Interior Decorator
• Prior to my training, I didn’t really spend time shadowing Nurse Practitioners or Physician Assistants but should have. I will be entering academic community pediatrics in an urban setting and the overwhelming majority of my mentors and folks whose careers inspire me are Pediatricians. However, if I was interested in more community or rural medicine, pursuing a career as a  Nurse Practitioner or Physician Assistant would have been a possible alternate route to providing primary care with much less debt and better work-life balance.

MiM Mail: Whose dreams come first?

My name is Jenny and I am 24. I am a single mother to a beautiful 6 year old and a handsome 5 year old. Their father is not really a part of the picture. I receive no financial support from him and he sees the kids once a week for about 8 hours.

I am a research assistant at an amazing lab and absolutely love research. I have planned on going back to grad school soon. The grad school where I'm located also has a med school and there is a MD/PhD Program. I have always dreamed of going to med school. It was my dream since I was 12. And even when I became a teen parent, I still knew I wanted to go to med school. But I never thought I'd had to go as a single parent, so I've gone a different path which has led me to research. As I start to prepare to apply my heart screams with such a passion that it becomes difficult for me to hold back the tears. Med school is where my dreams are. Research driven physician is where my heart is. It's what I've always wanted. But I'm a mother now and a single mother. The program is ideal because of the stipend. I cannot take 4 years off work to go to med school when I have children. But with a stipend I could get by. And I know I have to apply. Even if I don't get accepted, I have to apply. But if by some miracle I do get accepted would it be right for me to go? I have been in school for the majority of my children's lives. If I was to do the program, my kids would be adults when I finished. My daughter would be 19, my son going on 18. I would have spent my children's entire childhood in school. How is that fair to them? I would be so busy with school there would be no dating, no man to step up and be a step father. It would just be us with me always in school and studying. My kids will be adults. I'll be 37. And eventually that will happen anyways, but how much will we sacrifice if I kept going for my dreams? Isn't the mother supposed to put the child's dreams first? I don't know what to do. I feel either choice I make will break my heart. I would appreciate any feedback.

Thank you,
Jenny

In between promise and fatigue: here's to the end of residency

“Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams.”

“Before a dream is realized, the Soul of the World tests everything that was learned along the way.”

“Every search begins with beginner’s luck. And every search ends with the victor’s being severely tested.”

I can see the end of residency. My schedule is set. I know that June 23 is my last official day of my pediatric residency. I am standing on the edge: the edge of my time as a “trainee” and the beginning of my time as an Attending Pediatric Physician. As one of my closest mentors says, “Medicine is about delayed gratification,” and she is so right because I can feel the end of training, it’s palpable. It stands looming in the distance. I see the promise - the chance to continue to create the career that I have envisioned for so long. One committed to the underserved, adolescents, and new families. One committed to medical student education and helping to forge a path in medicine where the marginalized student feels less alone. One committed to enhancing trainees understanding of health literacy, compassionate care, holistic care. One committed to clinical excellence and rigor.

I can feel the promise of creating a career where I can share more of the child-rearing responsibility with my husband. We have had the chance this year to experience up to 2 consecutive months of me having a “regular” or non-Ward schedule and it has been amazing (family dinners, weekend outings, dates, sleeping in). My Attending friends tell me that this is how life can be post-residency and that I have to work hard to get a schedule that allows us to feel more like a regular family. Interviews have been going very well, but none has felt quite like “the one.” I can feel “the one” coming though and am giving myself until April to keep searching and networking.

But I can also feel my fatigue. It also stands looming and sometimes sneaks in for a jab or two. The tight pull of my neck as I continue to type into our electronic medical record. The beginnings of a tension headache as I work on licensing applications during Zo’s nap time. I can feel my strain and my friends’ strain as we begin conversations about our final residency rotations with “I am soo over this!” Invariably all of our texts, phone calls, and in person conversations include our “being over” being on call, covering in the wards, and Interns doing crazy things. Then we laugh and talk about how a friend who is a new Attending has told us something wonderful about his or her life.

As my Residency Director said, “You’re not supposed to love residency” because it’s not a permanent job, it’s just a big hulking stepping stone.

As I always do when I am straddling a new transition, I have begun to re-read selections of "The Alchemist." This book has been with me since the first time I read it in 2004 as a fourth year undergraduate awaiting medical school acceptances. This road has had its share of suffering. Times where I felt failure was imminent. I fought on. In spite of a few very low points, I have experienced joy beyond what I ever could have imagined. Providing excellent patient care, figuring out diagnoses, being hugged and hugging amazing families and assisting them during their lives’ lowest points. I have experienced the joy of getting married to an amazing man that I now call my own and together we welcomed to the world an outgoing, rambunctious little boy that amazes us every day. There isn't a day that we don't pause, smile or laugh out loud and shake our heads at his silliness and love for life.

As I stand on the edge of my most recent life’s transition, I foresee some suffering, some testing, and a whole lot of joy. While I welcome luck, I also know that I have been fortified by life’s challenges and know that you can experience fatigue and promise simultaneously and it still bring so much joy.

Here’s to the end of residency!!!

Quotes above are from Paulo Coehlo's "The Alchemist," 1993.